Assessment of parental nurturing and associated social, economic, and political factors among children in the West Bank of the occupied Palestinian territory (WB/oPt)

Parenting refers to the activities of raising the children to enable them to survive, grow, and develop to their maximum potential [1]. The literature identifies two dimensions for parenting: discipline and nurturance [2]. Parental nurturing or warmth that includes both maternal and paternal warmth is a broad notion entailing caring for children, their friends and their activities, encouraging them, supporting them, involving them and praising their achievements [3, 4]. Parental nurturing forms the base for the emotional and social means through which children develop trust, self-confidence, security feeling and competence [5, 6].

Parental nurturing is a cornerstone in the formation and development of personality and psychology of children and has received considerable research attention [7]. Several studies demonstrate a negative association between low parental nurturing and social behavior, academic success, and work achievement [8, 9]. Researchers found a positive association between school achievement and positive parenting practices which reflect the specific behaviors used by parents to raise their children such as reward and punishment [10‐12]. Parenting practices play an important role in protection against internalizing behaviors such as anxiety and depression as well as externalizing behaviors such as aggression [13]. Russell has examined the relationship between child misbehavior and the positive parental interaction and reported that love and affection are negatively associated with children’s misbehavior and hostility [14]. Lack of love and affection and poor parent child relationship has been shown to make children more susceptible to psychological disorders such as stress, anxiety and depression [4, 15].

Several factors have been reported to affect parental nurturing and affection. Those include child characteristics such as age, gender, physical and mental health and disability [16, 17]. In addition, family socioeconomic status, the child’s ordinal position in the family [10, 18‐20], family history and life situation, cultural beliefs and way of child rearing or parenting [21, 22], marital status and parental conflicts are major determinants [23, 24]. In a study conducted to determine predictors of parenting during early childhood Waylen and Brown reported that good maternal health and social support were positively related to high parental nurturing [25]. Furthermore, other research reported a negative association between use of corporal punishment and levels of emotional warmth [26]. Poor parent child relationship and domestic violence were found to increase risks of child maltreatment [27]. In 2013, Carroll and colleagues reported a significant inverse association between child abuse and parental warmth [28]. Overall, social, economic, and political factors are major determinants of quality of parental nurturing [7].

Children are sensitive to the surrounding environment and more likely to develop psychological distress due to domestic violence [29] and political turmoil [30]. Disruption of social, economic, and political aspects of life have been reported in areas experiencing conflict, fragility, and instability [31]. This toxic environment and the resulting social and individual stress are likely to reduce capacity of the parents to provide optimal nurturing and care for their children which is necessary for their wellbeing and development [7].

In the occupied Palestinian territory (oPt), there is a chronic lack of political stability [32]. A study conducted in 2015 by the Palestinian Central Bureau of Statistics (PCBS) in collaboration with UNICEF reported that 92.2% of the Palestinian children aged 1 to 14 years experienced one or more forms of physical or psychological violence in the month preceding the survey [33]. Given that parental nurturing plays an important role in child psychological wellbeing [34] and in neutralizing effects of political and domestic violence [30, 35], and because Palestinians continue to experience chronic and protracted political violence with negative economic and social effects, studying and understanding parental nurturing in the oPt is essential.

A study conducted in 9 countries -including Jordan, a country with similar social, religious, and cultural profile to the Palestinian context, and Colombia which has undergone decades of political instability- to assess parental warmth, acceptance and hostility towards children concluded that parents demonstrated high levels of warmth and acceptance in all countries studied [36]. To our knowledge, this is the first study on parental nurturing in the oPt at the national level. This study aims to evaluate levels of parental nurturing among Palestinian children aged 0–12 years living in the West Bank (WB) and to determine its selected social, economic, and political associated factors. We hypothesize that (1) the Palestinian mothers of the WB exhibit high levels of parental nurturing, (2) child discipline is inversely associated with parental nurturing, and (3) parental nurturing has social, economic and political associated factors.

Table 1 below shows the basic characteristics of the study sample. 52.5% were males, 53.0% were less than 6 years old, 24.6% of the families had 8 members or more, 61.3% of children were last in the family index, 22.5% of the mothers reported post-secondary education, 10.5% of the children were with one or more disabilities, 33.0% experienced high levels of discipline, 37.8% were living in urban areas, 45.5% were living in North WB and 41.0% were children whose families were exposed to political violence.

19.9% of the children experienced low levels of parental nurturing (Table 2). Mean level of parental nurturing was 91.9 (SD ±15.4) on a 100-point scale. No significant differences were detected by child gender. Parental nurturing varied by children’s age group: 16.2% of children aged less than six years; 20.5% of children aged 10 to 12 years, and 33.8% of children aged 10 to 12 years experienced low levels of parental nurturing (p < .05). 18.9% of nondisabled children had low levels of parental nurturing compared to 27.9% of children with one or more disabilities (p < .05). 14.8% of children subjected to low to medium levels discipline had low levels of parental nurturing compared to 30.3% of children subjected to high levels discipline (p < .05). 14.7% of children whose families were not subjected to political violence had low levels of parental nurturing compared to 27.3% of children whose families experienced political violence (p < .05). When we crosstabulated the region (north, center, and south) with education, employment, and family size, higher educational levels of mothers and higher employment rates in the family, and lower family sizes were noted for the North compared to the South WB).

Multivariate binary logistic regression using the categorized parental nurturing as the dependent variable is presented below (Table 3). No differences were detected by gender. Children aged 0–6 years were more likely to have high levels of parental nurturing compared to older children [OR = 3.07, 95%CI (1.90–4.96)]. Children who were last in the family were more likely to have high levels of parental nurturing compared to first or only child in the family index [OR = 2.20, 95%CI (1.20–4.03)]. Children with no disability were more likely to have high levels of parental nurturing compared to children with one or more disabilities [OR = 1.95, 95%CI (1.17–3.25)]. Children exposed to low to medium levels of discipline were more likely to have high levels of parental nurturing compared to children subjected to high levels of discipline [OR = 2.16, 95%CI (1.54–3.03)]. Children from urban areas were more likely to have high levels of parental nurturing compared to children from Palestinian refugee camps [OR = 2.25, 95%CI (1.18–4.29)]. Children living in North WB were more likely to have high levels of parental nurturing compared to children living in South WB [OR = 4.59, 95%CI (3.04–6.92)]. Children whose families were not subjected to political violence were more likely to have high levels of parental nurturing compared to those whose families were exposed to political violence [OR = 1.93, 95%CI (1.38–2.70)].

We used secondary data representative of Palestinian children living in the WB of the oPt based on the Palestinian Census Projections of 2007 to estimate levels of parental nurturing among children aged 0 to 12 years and to uncover some of the associated social, economic and political factors. The Palestinian mothers living in the West Bank reported high levels of parental nurturing. Parental nurturing was found to be influenced by the social, economic, and political conditions the Palestinians are enduring. Child discipline was negatively associated with parental nurturing. These findings are in line with our proposed hypotheses. Overall, 19.9% of the children were at risk of receiving low levels of parental nurturing.

The result indicated that younger children below 6 years old were more likely to have high levels of parental nurturing compared to older children. This finding is supported by study of Chen and Liu which indicated a change in parenting practices at different stages of the child’s development [45]. McNally and colleagues attributed this to changes in children’s dependency, and emotional and academic support required from their families [46]. In 1984, Roberts and colleagues reported that when children grow up and move toward adolescence, they are more likely to have greater degree of autonomy and freedom [47]. As a result the parent’s role in control, involvement, supervision and interaction with their children is reduced, leading to changes in parental nurturing levels [20, 47].

Children who were last in the family were more likely to have high levels of parental nurturing. Indeed, research has shown that parental practices and responses differ by family size and the ordinal position of the child in the family [20]. Kidwell reported that when more births occur in the family, the first child’s central position and opportunities to have considerable attention, affection, and support is reduced leading to lower levels of parental nurturing [48]. This could also be a function of age. The last child is the youngest in the family and it could well be that attention and communication, with parents is highest among last children. Indeed, a local Palestinian saying about the last child describes the child as ‘the last in the bunch of grapes or clusters’, understood as the last child receiving most attention and being most loved.

Nondisabled children were more likely to have high levels of parental nurturing. A meta-analysis conducted to check whether relationship between child parents and parenting practices differ in families who have children with chronic illnesses and those who do not reported similar findings [49]. Parenting practices and parent child relationship play an important role in behavioral adaptation in children with chronic illness including, for example, adherence to prescribed diabetes medication [50]. Additionally, Roberts and Lawton emphasized that disabled children need extra parental care and efforts compared to healthy children, leaving insufficient time and energy for optimum parental nurturing [51]. Also, child disability adds economic burden on parents causing stress which interferes with parental affection and care [52]. High levels of stress among parents may lead to depression known to negatively affect parental nurturing [53, 54].

Children exposed to low to medium levels of disciplinary methods were more likely to have high levels of parental nurturing. In 2001, Wade and Kendler reported that physical discipline was inversely associated with parental nurturing a finding which endorses our finding [55]. In a review of the literature, Walters and Stinnet concluded that parents who showed acceptance, support and love to their children yielded better social and emotional child development, while rejection and punishment negatively affected the child’s emotional and social development [20]. Parents who reported using more abusive methods of punishment were less likely to have positive interaction with their children and more likely to utilize disciplinary approaches [56].

Parental nurturing was found to vary by type of locality. Children from urban places were more likely to have high levels of parental nurturing compared to children from Palestinian refugee camps. Palestinian refugee camp dwellers are disadvantaged and often suffer from poverty, unemployment, unhealthy and overcrowded housing conditions [57, 58]. High levels of psychological distress reported among refugees have been attributed to the deteriorated social, economic and political environment [59‐62]. The way camp residents live where there is a lack of basic human living requirements such as personal and family safety, economic prosperity, good housing, and food security [63, 64] are believed to be the main causes of the psychological distress and depression that interferes with levels of parental nurturing [54].

Parental nurturing was associated with region. Children living in North WB were four times as likely to have high levels of parental nurturing compared to those living in South WB. This was a major finding in our study. Underlying causes of this pattern of nurturing are not well known and further investigations are required to identify main causes of this finding. However, economic, political, and developmental conditions could be an explanation. The southern region of the West Bank is the most populated region of the west bank, and the Hebron district in particular is known to have the lowest levels of educational attainment among its population including the highest levels of illiteracy, the highest mean number of children, the lowest level of access to safe drinking water, and the lowest proportion of computer access at home [65, 66]. These results generally correspond to a 2002 study which demonstrated that the southern region in general and the Hebron district in particular is less exposed to the outside world, with more conservative social and cultural characteristics than the rest of the West Bank which can help explain the results of this study [67]. Furthermore, other investigations have reported high levels of exposure to violence in the Hebron district [68]. Overall, the use of discipline, large family sizes and crowded homes were more prevalent in south WB, while the educational levels of North West bankers were higher than those from the south, which can also help explain the results.

Children whose families were not subjected to political violence were more likely to have high levels of parental nurturing. Parental nurturing cannot be understood without proper investigation of the social, economic and political context [69]. Those who experience political violence are at greater risk of developing fear and distress [70]. In the oPt political violence was found to be associated with increasing occurrence of mental health problems including trauma and stress [71]. In addition, exposure to political violence has a deleterious effects on family function leading to economic burden, stress, somatization, anxiety [72] and increases the risk of child abuse [73]. Such factors could explain low levels of parental nurturing among families experiencing political violence.

Although Palestinian mothers showed high levels of parental nurturing as we expected, around one-fifth of the children are still at risk of receiving low levels of parental nurturing. Risk factors identified in this study include age of the children, their ordinal position in the family, disabled children, refugee camp dwellers, South WB children, and among families exposed to political violence. Some of these associated factors are modifiable with intervention programs focused on the identified priority groups of children. This could include improving the daily living conditions of families, providing social, and economic support to disadvantaged groups such as those living in the refugee camps, which has been shown to improve the overall levels of parental nurturing [7]. Our results nevertheless emphasize the impact of social, economic and political dimensions on health. More attention should be paid to improve daily living conditions and health needs of children at risk. Ultimately, a just political solution to the Palestine question especially as this relates to Palestinian refugees is also of essence.